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Wednesday, July 10, 2019

What Do Vets Really Know About Nutrition, Anyway?

     As pet owners, we constantly face an onslaught of contradictory information regarding what's best for our pet's health and well-being, complicating the pursuit of making informed decisions. Perhaps no topic is more egregious than that of nutrition, where the wealth of misinformation has grown so tall, people have become wary of trusting even the input of their veterinarian. Many companies have pursued marketing tactics that de-legitimize the words of licensed and boarded experts, hoping to sway owners against research-backed formulas in favor of new fads and bold claims. They say that vets don't receive any training in nutrition, and that they're told to simply recommend the big brands. This may leave one to scratch their head and wonder-- what does my vet really know about nutrition, anyway? Did she even receive formal education on the topic? Does he know the first thing about evaluating ingredients?

     The truth is, most veterinary schools in the US have a wonderful nutrition curriculum, over half employ a boarded American College of Veterinary Nutrition diplomate, and veterinary students enroll in both required and elective nutrition courses. The curriculum requirements for a veterinary college to be considered accredited in the US are stringent, and include providing "an understanding of the central biological principles and mechanisms that underlie animal health and disease from the molecular and cellular level to organismal and population manifestations," and "knowledge, skills, values, attitudes, aptitudes and behaviors necessary to address responsibly the health and well-being of animals in the context of ever-changing societal expectations." One of the 9 competencies expected of all US graduates is "critical analysis of new information and research findings relevant to veterinary medicine," meaning that even in regards to the ever-changing nature of medicine, a veterinarian must be capable of interpreting and reviewing research findings.

     There should be no doubt that nutrition is considered to be medically pertinent by the veterinary profession as a whole. The World Small Animal Veterinary Association (WSAVA) has provided guidelines for nutritional assessment since 2011. The association maintains that nutritional assessment is one of the five vital signs to be evaluated in the basic physical exam of all small mammals, along with temperature, pulse, respiration, and pain assessment. The 12 page document guides the practitioner through conducting a thorough assessment of the animal's nutritional status and ongoing needs. This document does not provide any specific food or brand recommendations for veterinarians to provide their clients, but instead offers criteria for consideration during commercial diet evaluation. The American Animal Hospital Association (AAHA) has also provided similar guidelines, likewise asserting that nutrition is an integral part of animal health and wellness. Finally, the American College of Veterinary Nutrition (ACVN), established by the American Academy of Veterinary Nutrition (AAVN) in 1984 to develop nutrition as a boarded specialty, has published a document of nutritional competencies of small animal veterinarians, a list of functions that all small animal vets should be able to perform upon graduation, even without specialization. The three page list of competencies includes:

  • Determine adequacy of the current diet for the physiological status of the animal
  • Understand the functions of nutrients and the role of ingredients and nutrients in health and disease
  • Differentiate between the presence of diet-induced and nutrient-sensitive disease
  • Provide assistance to formulate an adequate home-prepared diet when necessary, referring to ACVN Diplomate as needed
  •  Assist the client in choosing appropriate diets for their pet’s lifestage, activity and physiology, consistent with the client’s personal preferences
  • Evaluate nutrition-related information presented in journals and other professional texts
  • Evaluate validity of nutrition-related marketing claims

     Though it should be clear that there is an expectation for nutrition knowledge within the profession, curriculum and competencies are just on paper-- what about a first hand account of what happens behind closed classroom doors? To recount my own first year introductory nutrition course: 

Our classroom was not sponsored by Nestle or Mars. I paid approximately $900 in tuition for this single course. Some of my out of state colleagues paid closer to $1400. Our professor was not some random marketing rep from a pet food company. He’s a faculty specialist at the campus veterinary hospital. He’s boarded in not only nutrition, but also internal medicine. In addition to his veterinary degree and specializations, he holds a Master’s in medical science and a PhD in veterinary medicine. 

Among other objectives, we were expected to learn the following:
  • Macronutrients, their role in the diet, their sources, digestibility / quality between the sources, and results of deficiency and excess
  • Micronutrients, their role in the diet, their sources, bioavailability differences between sources, combinations of ingredients that can limit their bioavailability, and medical conditions, activity levels, and other factors that increase or decrease the amount of those nutrients needed in the diet
  • How to evaluate a nutrition label and mathematically determine the calories attributable to each macronutrient 
  • What factors alter the metabolism and therefore caloric needs of dogs and cats
  • Laws that govern the pet food industry and gaps in legislation that leave certain aspects unregulated
  • What factors impact palatability
  • Differences between dry, moist, cooked, and raw diets
  • Nutritional needs for puppies, kittens, pregnant and lactating bitches and queens
  • Ways to determine digestibility, factors that alter digestibility, and average digestibility of common protein and carb sources
  • The role of the colon microbiome in the digestion of insoluble fibers

We studied dogs, cats, horses, and both beef and dairy cattle needs extensively. We also had a summarized unit on small species such as rodents and rabbits. If we choose to pursue it, a later elective course on exotic nutrition is available. 

We had to sit down and formulate a homemade diet that was complete and balanced to meet all essential dietary for a dog. We weren’t allowed to leave the lab until we had a recipe that worked, within 10% of all the nutrient needs. It took most of us several consecutive hours. 

We had to do a 5 page write up on our own pet’s food and discuss all the individual factors that affect our specific pet’s nutritional needs, such as activity, age, breed, any pertinent disease states, and even the temperature at which we keep our house or apartment.

This is just a summary of what the course entailed- it was by no means a walk in the park. It was an intense, rapid-fire, in-depth course on animal nutrition, and considered only a basic introduction to the subject. 

     So what of the well-perpetuated myth of payoffs and kickbacks from the major companies? We do have sponsored lunches at the vet school-- Purina most frequently hosts these, and one of the veterinarians (not a marketing representative) that works for the company gives a lecture on one of their products. These lectures do not consist of a sales pitch for Purina diets. Instead, they're usually a summary of the company's most recent research on a specific prescription diet. Last year, we had a lunch lecture about the Overweight Management diet, which focused first on a discussion of obesity as a problem in pets, and second on what research was conducted by Purina to substantiate the effectiveness of their prescription food. We also had a lunch lecture on their new probiotic product, Calming Care, where an overview of the research conducted on BL999 bacterial strain for the treatment of anxiety was discussed. 
     These lectures are important. They allow young veterinary professionals to be exposed to marketing early in their career and learn how to critically analyze a product, the research backing it, and assess how it stands up to competing products. They are not presented with the intent of swaying students to favor one brand or another. In fact, the American Association of Veterinary Medical Colleges has published in their policies and procedures manual (pages 36-39) "Guiding Principles and Consideration: Ethical Interactions Between Schools/Colleges of Veterinary Medicine and External Entities" to help mediate the potential for bias introduction during these sponsored events. 

     Similar lectures are sometimes offered as "Lunch & Learn" Continuing Education (CE) for veterinary clinics. These lectures are also offered by drug representatives (manufacturers of vaccines, prescription drugs, and nutraceuticals), surgical tool representatives, laboratory analytical device representatives (such as IDEXX and Abaxis, who sell products for in-house blood work) and various other retailers of products pertinent to the practice of veterinary medicine. These lectures provide an advertising avenue for these companies, yes, but also allow veterinary professionals to utilize their education to critically evaluate the products being offered to them. Veterinary medicine cannot be practiced in a vacuum-- there are tools required for the trade, some of those tools are products, such as foods, drugs, and devices, manufactured by third party companies, because the role of the veterinarian is a health care provider, not a manufacturer. 
     As medical professionals, it is not the job of a veterinarian to blindly accept any product marketed towards them. Rather, they utilize their educational background to critically evaluate what products are the best solutions for their patients, based on research and a scientific foundation. Things like prescription diets are not money makers for the practice. Veterinarians are not the profiteers of the pet food industry. While diets may be offered at a discount to a clinic that opts to regularly stock them, this discount is often passed on to the client, for the sake of convenience. Even with a mark-up, the profit margins for pet foods in a clinically setting is notably low. More money can be made off of a routine toe-nail trimming than selling a bag of food.  

      For more on this topic, check out "Are Vets Bought by Big Pet Food?"

     Now, all of this is not to say that every single veterinarian is an expert on nutrition. There are  certainly veterinarians that don't feel comfortable discussing nutrition with clients, and others who have become emotionally exhausted with the task and have decided that it is not worth the struggle of arguing with clients that are convinced that they know better. However, by all current field standards, nutritional assessment is considered part of a basic exam that all veterinarians should be competent in conducting. If your vet is comfortable discussing nutrition with you, you should feel confident that the advice they have to offer is more sound and educated than the advice offered by a breeder, pet enthusiast, trainer, or feed store employee. 

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Are Vets Bought By Big Pet Food?

     In light of the recent FDA investigation into dietary DCM in dogs, the age old concern that veterinarians are bought and paid off to recommend "Big Pet Food" (Nestle Purina, Mars (Royal Canin, Eukanuba, Iams), and Hill's) has returned with a vengeance.

     The reality is, vets recommend those brands because they are, unlike many offered across the US, heavily research-backed and evidence-based. The companies employ experts (Diplomates of the American College of Veterinary Nutrition, PhD scientists with focuses in Animal Science, Nutrition, Toxicology, etc) to formulate and evaluate their diets. They conduct extensive feeding trials that exceed AAFCO minimums before releasing new formulations to the public. They conduct and invest in research, then proceed to have that research peer-reviewed for bias and published in scientific journals for other companies and professionals to reference and utilize. These brands are the only ones offered in the US that meet the highest standards for all of the recommendations made by World Small Animal Veterinary Association Global Nutrition Committee.

     While concern has been expressed that some WSAVA events and conferences have been sponsored by Mars and Nestle, these guidelines are nonetheless impartial and non-exclusionary. WSAVA does not certify or approve or endorse any manufacturers for meeting these recommendations. They provide the recommendations for owners and veterinarians to utilize on their own for evaluation of any given manufacturer. 

  1. Companies should employ experts. Employing multiple experts is better than a single expert, which is better than consulting with an expert, which is better than not involving an expert at all. Companies should be transparent and be able to name their nutritionist and provide their qualifications and credentials. 
  2. The individual(s) formulating diets should be well-credentialed and qualified to be doing so. 
  3. All foods should meet AAFCO standards for complete and balanced. Meeting that standard using feeding trials is preferable to formulation or analysis alone. Feeding trials should be conducted on all or most formulas, not simply a select few.
  4. Food should be produced and manufactured in a clean, monitored facility. Companies should be willing to disclose information on where their product is made.
  5. Companies should be able and willing to describe their specific quality control measures.
  6. Companies should be able and willing to provide a complete nutrient analysis for their food. 
  7. Companies should be able and willing to provide the calories per gram of their products.
  8. Companies should conduct research and publish that research in peer-reviewed scientific journals. 
     All pet food manufacturers should be striving to meet high standards for each of these recommendations. Currently, only the "Big Food" brands are doing so. 

     It is also true that Nestle, Mars, and Hill's provide research grants and scholarships to veterinary professionals and students. They also sponsor conferences for continuing education. Its important to note that the sponsorship does not mean that marketing reps get to give lectures about why their food should be sold, nor does it indicate an agreement to recommend or sell that brand. Instead, it usually means that employees get discounted conference attendance, and the company gets a booth in the conference's product hall. Medicine cannot be, and never will be, practiced in a vacuum. Practicing vets cannot craft their own surgical instruments, engineer their own blood analysis machines, build their own clinics, chemically formulate their own pharmaceuticals, or, most relevant in this case, manufacture their own lines of companion animal diets. Part of the medical professional's job is to critically evaluate the goods advertised to them, and be discerning consumers in order to provide the best for their clients. If those goods are created by companies that employ professionals, they are more likely to meet the high standards that the discerning practitioner is looking for. 
     These companies unabashedly support the veterinary medical community, but one should critically ask themselves why that would be considered a bad thing. The profits of these companies are quite literally invested in animal health and the professionals that take an oath to protect it. Where are the profits of other companies going, and why do those companies not support veterinarians?

     None of the support offered by these companies (which is never in the form of 'kickbacks') changes that they are strongly backed by research, science, and decades of commitment to animal health. That is why they are recommended.